Neuro Flashcards
Causes of headaches in children?
Primary
* migraine
* tension
* cluster
Secondary:
* Meningitis (esp. viral)
* encephalitis
* abscess
* head injury
* Reye syndrome
* sinusitis
* medicaiton overuse
* substance abuse or withdrawal
* menstruation
* malignant hypertension (check BP)
* idiopathic
* intracranial hypertension (raised ICP)
* stress
* behavioural
* infection e..g ENT
* brain tumour
* carbon monoxoide poisoning
Red flags for headaches in children?
LOTS !
- fever
- altered consciousness
- suddent onset
- worse in morning
- varies with posture
- wrose with cough / valsava
- wakes from sleep
- unexplained vomitting (esp. early morning)
- recent head trauma
- young <4 years
- bulging fontanelle
- neurological signs
- visual disturbance
- rapidly increasing head circumference
- cognitive decline
- history of malignancy
- immunosuppressed
- early or late puberty
- signs of raised inctracranial pressure.
What are the presenting features of tension headache in children?
site, charachter, relevant negatives
- mild ache across the forehead diffuse
- pain or pressure in a band-like pattern around the head
- comes on and resolve gradually 30min - 7 days
- symmetrical
Negatives:
* no visual changes
* no pulsating sensations.
* not excaerbated by activity
* no nausea / vommitting
day to day symptoms of tension headache that might present in the history for younger children?
- often very non-specific in younger children.
- quiet
- stop playing
- turn pale tired.
- They tend to resolve more quickly in children compared with adults, often within 30 minutes.
Triggers for tension headaches in children?
- Stress, fear or discomfort
- Skipping meals
- Dehydration
- Infection
Management of tension headache in children?
- Reassurance
- Analgesia - Paracetemol / ibuprofen
- Regular meals
- Avoiding dehydration
- Reducing stress.
Migraines are a complex neurological condition that cause headache and other associated symptoms. They occur in “attacks” that often follow a typical pattern.
What are different types of migraine?
- Migraine without aura
- Migraine with aura
- Silent migraine (migraine with aura but without a headache)
- Hemiplegic migraine
- Abdominal migraine
Symptoms of migraine in children? What are they often associated with?
- Unilateral
- More severe
- Throbbing in nature last 1-72 hours
- Take longer to resolve
Associated with:
* Visual aura
* Photophobia and phonophobia
* Nausea and vomiting
* Abdominal pain
* vertigo
* visual or senory aura
* aggravated by physical activity
Triggers for migraines in children?
- diet
- dehydration
- overtiredness
- stress
Management of migraines in children?
- Rest, fluids and low stimulus environment
- Paracetamol
- Ibuprofen
- Sumatriptan if above does not work and >12yrs
- Antiemetics, such as domperidone (unless contraindicated)
If migraines are having a big impact on life e.g. missing school / frequent what options are there for prophylactic treatment for migraines to reduce frequency / severity ?
- Propranolol (avoid in asthma)
- Pizotifen (often causes drowsiness)
- Topiramate (girls with child bearing potential need highly effective contraception as it is very teratogenic).
Non drug:
* get enough sleep
* avoid triggers
What are abdominal migraines? how do they present?
- common in children especially young children
- central abdominal pain > 1 hour
- Nausea and vomiting
- Anorexia
- Headache
- Pallor
pt with possible migraines ask about abdo pain as a child.
What are abdominal migraines? how do they present?
- common in children especially young children
- central abdominal pain > 1 hour
- Nausea and vomiting
- Anorexia
- Headache
- Pallor
pt with possible migraines ask about abdo pain as a child.
Infections can cause headaches: what common infections should you check for? When should headache resolve if these are the cause?
- viral upper respiratory tract infection, otitis media, sinusitis and tonsillitis.
- headache should resolve along with the infection.
- Paracetamol and ibuprofen for symptomatic relief.
How can sinusitis cause headache? what symptoms does this cause? what is the cause of most sinusitis?
- causes a headache associated with inflammation in the ethmoidal, maxillary, frontal or sphenoidal sinuses.
- facial pain behind the nose, forehead and eyes.
- tenderness over the effected sinuses
- Sinusitis usually resolves within 2 – 3 weeks.
- Most sinusitis is viral.
Subdural haemorrhage why is it important to think of non - accidental injury?
- SDH in children <2 yrs is big cause of mortality and morbidity
- significant number are caused by purposeful inflicted trauma
What are some causes of subdural haemorrhage in children?
- Trauma (including traumatic labour).
- Neurosurgical complications.
- Cerebral infections.
- Coagulation and haematological disorders.
- Metabolic causes (glutaric aciduria, galactosaemia).
- Biochemical disorders (hypernatraemia).
oxford handbook of paediatrics
What are symptoms / signs of acute subdural haemorrhage in children?
- Encephalopathy (irritability, lethargy, focal neurological signs).
- Vomiting, poor feeding.
- Breathing abnormalities, apnoea.
- Pallor, shock.
- Tense fontanelle.
- Seizures (more frequently in inicted than non-inicted injury).
Symptoms signs of chronic subdural haemorrhage in children?
- Expanding head circumference.
- Vomiting
- failure to thrive
- Neurological deficit.
- Associated conditions
What is an opthalmolgy finding you might get in a non-accidental head inhury (NAHI) i.e. in a child with a subdural haemorrhage.
- retinal haemorrhages are strongly associated with NAHI
- however : not specific for diagnosis
- child with heady injury have an opthalmoligst assess
A child presenting with a bleed in brain i.e. subdural haemorrhage what causes do you need to exlude? What tests would you do?
Coagulation and haematological disorders need to be excluded.
Tests:
* FBC, platelet count, blood film.
* Renal and liver function tests to rule out numerous acquired coagulation defects
What brain imaging for a child with subdural haemorrhage?
Initial investigation is likely to be CT, but MRI will also be necessary.
Management of subdural haemorrhage?
Hx, tests, assessment, referral etc
- Take full social, medical, and family history.
- Skeletal survey.
- Clotting assessment.
- Store urine in case needed for organic acids (GA1 rare cause of spontaenous SDH).
- Arrange ophthalmology assessment.
- Treat sequelae of SDH: depends on presentation (e.g. seizures and AEDs) and resuscitation needs.
- Complete safeguarding procedures: involve external agencies (e.g. social services, police).
- Multidisciplinary and specialist follow-up
Management of subdural haemorrhage?
Hx, tests, assessment, referral etc
- Take full social, medical, and family history.
- Skeletal survey.
- Clotting assessment.
- Store urine in case needed for organic acids (GA1 rare cause of spontaenous SDH).
- Arrange ophthalmology assessment.
- Treat sequelae of SDH: depends on presentation (e.g. seizures and AEDs) and resuscitation needs.
- Complete safeguarding procedures: involve external agencies (e.g. social services, police).
- Multidisciplinary and specialist follow-up
Epilepsy in children: how is it defined? what type of seizures are most common?
- Defined by (mostly) unprovoked, recurrent seizures - transient episodes of abnormal electrical activity in the brain.
- 1% per cent of children will have one afebrile seizure by the age of 14yrs
- The majority will be generalized tonic–clonic (GTC) episodes.
What are generalsied tonic-clonic seizures?
- loss of consciousness and tonic (muscle tensing) and clonic (muscle jerking) movements.
- Typically the tonic phase comes before the clonic phase.
What other symptoms happen in a generalised tonic-clonic seizures with? what happens after the seizure?
- associated tongue biting, incontinence, groaning and irregular breathing.
- prolonged post-ictal period where the person is confused, drowsy and feels irritable or low.
Treatment for tonic-clonic seizures?
- First line: sodium valproate
- Second line: lamotrigine or carbamazepine
What is epilepsy ?
This is a tendency to recurrent, unprovoked seizures (abnormal electrical brain activity).
1% of children will have a seizure (not associated with fever) by the age of 14 years.
oxhandbook of specialities : paediatrics
What are types of generalised seizures you might get?
Usually a loss of awareness and can be:
- Generalised tonic/ clonic
- absences
- Infantile spasms
- other e.g. tonic, atonic, clonic, myoclonic
Describe briefly the following type of seizure: generalised tonic/clonic seizure
How is it managed?
GTC or grand mal:
* limbs stien (the tonic phase) and then jerk forcefully (clonic phase), with loss of consciousness.
* prolonged post-ictal period where the person is confused, drowsy and feels irritable or low.\
* may be associated tongue biting, incontinence, groaning and irregular breathing.
Management of tonic-clonic seizures is with:
* First line: sodium valproate
* Second line: lamotrigine or carbamazepine
Describe briefly the following type of seizure and tell me how it is managed: Absences (petit mal)
- typically in children
- blank, stares into space and then abruptly back to normal
- brief (eg 10-20 sec) pauses (‘He stops in mid-sentence, and carries on where he left off’)
- eyes may roll up
- he/she is unaware of the attack.
Management:
* First line: sodium valproate or ethosuximide
Describe briefly the following type of seizure and tell me how it is managed: Infantile spasms
- age: 3–9 months
- Brief (<2sec)
- movements with flexion of trunk and extension of limbs (‘Salaam attack’).
Management:
* Prednisolone
* Vigabatrin
Describe briefly the following type of seizure and tell me how it is managed: Other e.g. atonic
- drop attacks - brief loss of muscle otne
- <3 minutes
- begin in childhood
- may be indicative of Lennox-Gastaut syndrome
Management :
First line: sodium valproate
Second line: lamotrigine
Describe briefly the following type of seizure and tell me how it is managed: Other e.g. myoclonic
- myoclonic (brief, usually single, sudden contractions like a ‘jump’).
- patient usually remains awake during the episode.
- They occur in various forms of epilepsy but typically happen in children as part of juvenile myoclonic epilepsy.
Management:
* First line: sodium valproate
* Other options: lamotrigine, levetiracetam or topiramate
Describe briefly the following type of seizure: Other e.g. tonic, clonic,
- tonic (usually <1min sustained ↑ tone)
- clonic (rhythmic contractions)
Describe briefly the following type of seizure and tell me how it is managed: Focal seizures
start in the temporal lobes. They affect hearing, speech, memory and emotions.
- Hallucinations
- Memory flashbacks
- Déjà vu
- Doing strange things on autopilot
- focal motor twitches
- sensory or emotional disturbances
- automatisms (eg lip smacking, rubbing face) or events of pure pleasure.
- Todd paralysis
- <48h weakness of affected muscles
- may follow classic focal tonic–clonic seizures.
Management:
(the reverse of tonic-clonic seizures):
* First line: carbamazepine or lamotrigine
* Second line: sodium valproate or levetiracetam
In status epilepticus with a child what two times should you be aware of?
(SE can be convulsive with tonic/clonic movements OR non-convulsive w/ impairment of consciousness and subtle twitching)
- 5min (t1): the time from which treatment should given.
- 30min (t2): the time after which brain injury may occur.
Thinking about distinguishing between a febrile seizure and epilepsy. What should simple febrile seizure NOT look like as a way to exclude it?
- Should not be >15min.
- Should not involve focal or asymmetrical activity.
- Should not recur within 24h.
- Should not be associated with focal neurological findings.
Provided the FS conforms to the above criteria and there is full recovery, carers can be reassured and the child discharged home.
Why is a good history key in epilepsy in children?
- to distinguish it from febrile convulsions or vasovagal epsiodes
- Patients with a clear history of a febrile convulsion or vasovagal episode do not require further investigations.
How to diagnose epilepsy in children?
- difficult!
- NICE: all children with a first afebrile seizure needs to be seen by a specilaist in a first seizure clinic
- diagnosis focused on history and patients background
- examination and investigation revisited
- if diagnosis uncertain - further investigations / period of observation
- if confirmed - explain diagnosis, additional resources, outpatient EEG
What investigatins would you do for a child with suspected epilepsy?
- EEG
Typical patterns of different forms of epilepsy (DR T: do after their second simple tonic-clonic seizure - allowed one simple seizure before being investigated) - MRI brain
structural brain problems / pathology e..g tumours.
when child <2 years, focal seizures, no response to medication
Additional:
* ECG to exclude problems in the heart (long QT syndrome).
* Blood electrolytes including Na, K, Ca, Mg
* Blood glucose - hypoglycaemia + diabetes
* Blood cultures, urine cultures and lumbar puncture where sepsis, encephalitis or meningitis is suspected
What forms of epilepsy are there in children where EEG is diagnostic?
West syndrome ‘infantile spasms’- hip spasms
Absence - 3Htz spike
What are the causes of raised intracranial pressure ?
from LRI guidleins for raised ICP in children
Potentially serious complication of:
* traumatic brain injury
* CNS infection
* CNS tumour
* hydrocephalus
* hepatic encephalopathy
* severe hypertension
* intracranial bleeding from arteriovenous malformation
* impaired intracranial venous drainage.
chrome-extension://efaidnbmnnnibpcajpcglclefindmkaj/https://secure.library.leicestershospitals.nhs.uk/PAGL/Shared%20Documents/Raised%20Intracranial%20Pressure%20UHL%20Childrens%20Hospital%20Guideline.pdf
Management: you are suspecting raised ICP : what do you need to cover in history to rule in / out differencials?
LRI management guidleines
- Symptoms of meningitis or encephalitis?
- Hypoxic ischaemic injury the brain? (e.g. Post cardiac arrest)
- Metabolic? (DKA, inborn errors)
- Blocked shunt in hydrocephalus?
- Unexplained headache, vomiting, double vision/visual impairment?
- Traumatic brain injury (NAI, accidental)
If raised ICP is suspected what might you be looking for in the clincial exam?
- Drowsy
- seizures
- papilloedema (late sign)
- pupil changes (ipsilateral dilatation)
- abnormal posturing (decorticate / decerebrate)
- Cushing triad (bardycardia, increased BP, and irregular breathing = warn immeidate coning)
- Bulging fontanelle in very young infant
- Abnormal eye movement/ persistent eye deviation
- Reduced GCS</= 8
oxhandbook and LRI guidelines
What is the management of raised ICP?
- start without delay - NO Lumbar puncture
- Start resuscitation e.g. intubate and ventilate, ABC approach
- treat hypoglycaemia
- Give 3mls/kg of 2.7% sodium chloride or Mannitol (1gram/kg (5ml/kg) of 20% Mannitol over 15-30 minutes)
- Treat shock / hypotension
- Maintain a normal temperature, avoid hyperthermia
- Call for help
- Call anaesthetist early
- Call CICU
- Elevate head to 30° in midline position
- Treat seizures if present, consider prophylactic treatment for seizures (Phenytoin)
- Urinary catheter
- Neuro observation every 15 minutes
some say steroids e..g dexametheson can sometimes be used
What is spinal muscular atrophy? when does it start?
is a genetic disease that affects the motor nerve cells in the spinal cord, resulting in progressive muscle wasting and weakness.
It typically begins in infancy or childhood
What is the inheritance pattern of spinal muscular atrophy?
Autosomal recessive disease- males and females are equally affected
1 in 4 (25%) chance their child will have SMA
1 in 2 (50%) chance their child will be a carrier of the faulty gene, but will not have SMA
1 in 4 (25%) chance their child will not have SMA and will not be a carrier
What are the different types of spinal muscular atrophy?
- type 1 – develops in babies less than 6 months old and is the most severe type
- type 2 – appears in babies who are 7 to 18 months old and is less severe than type 1
- type 3 – develops after 18 months of age and is the least severe type affecting children
- type 4 – affects adults and usually only causes mild problems
What are some symptoms of spinal muscular atrophy?
depends on when they appear / what type but typical symptoms include
- floppy or weak arms and legs
- movement problems – such as holding their head up, difficulty sitting up, crawling or walking
- tremors
- bone and joint problems –e.g (scoliosis)
- swallowing / feeding / sucking problems
- breathing difficulties need support especially sleep / illness
no affect on learning / intelligence
What tests for spinal muscular atrophy ?
before pregnant, while pregnant , after birth
Pre-pregnancy:
* Genetic testing + family counselling if runs in family
During pregnancy:
* chorionic villus sampling 11-14 weeks
* amniocentesis 15-20 weeks
Tests after birth:
muscle biopsy - confirm diagnosis
EMG / nerve conduction studies
Treatment for spinal muscluar atrophy?
- feeding and diet support - gastrostomy / NG tube
- breathing support - exercises, suction
- pneumoccal and flu vaccines
- OT support for mobility e.g. wheelchairs, orthotics for walking
- physiotherapy : exercises
- if scoliosis ; back brace or spinal surgery
Medicine:
* nusinersen (Spinraza) – a medicine that targets the faulty gene, given as an injection into the spine, every few months
* risdiplam (Evrysdi) – a medicine that targets the back-up copy of the faulty gene, given as a liquid once a day
What is Duchenne muscular dystrophy?
How is it inherited?
X-linked recessive inherited disorder in the dystrophin genes required for normal muscular function.
What are the features of duchenne muscular dystrophy?
- progressive proximal muscle weakness from 5 years (lack of the dystrophin protein, muscle fibres break down and are replaced by fibrous and or fatty tissue)
- calf pseudohypertrophy
- Gower’s sign: child uses arms to stand up from a squatted position
- 30% of patients have intellectual impairment
Investigations for Duchennes muscular dystrophy?
Bloods:
creatinine kinase - raised
LFTs- ALT, AST - high due to muscle damage not liver problem
Genetic testing and counselling - has mostly replaced muscle biopsy
Management of Duchenne muscular dystrophy?
- no cure - largely supportive
- mobility assistance – including exercise, physiotherapy and physical aids
- support groups – to deal with the practical and emotional impact of MD
- surgery – to correct postural deformities, such as scoliosis
- medicine – such as steroids to improve muscle strength, or ACE inhibitors and beta blockers to treat heart problems
Prognosis for Duchenne muscular dystrophy?
- most children cannot walk by the age of 12 years
- patients typically survive to around the age of 25-30 years
- associated with dilated cardiomyopathy
Epidemiology of spinal cord injury in children?
incidence, demographics, anatomic location
e.Incidence
* 2-5% of all spinal cord injuries
* 83% involve the cervical spine
Demographics
* more common in males 1.5:1
* cervical spine injuries more common in children aged <8 years due to large head-to-body ratio
* thoracolumbar spine injuries more common in children aged >8 years
Anatomic location
* upper cervical spine injuries (C1-4) e.g occipito-atlantal or atlanto-axial dissociation are more common than lower cervical spine injuries (C5-7)
Causes of spinal cord injury in children?
- Motor Vehicle Accidents (esp. young children)
- Sports (adolescents more common)
- Trauma e.g. Non accidental injury, birth injuries, falls
- Non-traumatic e.g. instability of the upper cervical spine (Down syndrome), spinal stenosis seen in skeletal dysplasias, and inflammatory conditions, such as juvenile rheumatoid arthritis
- Phenomenon of spinal cord injury without radiographic abnormality (SCIWORA).
https://www.physio-pedia.com/Paediatric_Spinal_Cord_Injury
Why is the pathophysiology of spinal cord injury different in children compared to adults?
- spine in <8 is hypermobile
- head is larger than body in children - the occipitoatlanto complex is at risk
- The childrens vertebrae is not completely ossifiied and lax ligaments increases the risk of ligamentous injuries
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6513171/
How might a child with a spinal cord injury present?
- Spinal Shock - Pronounced loss of sensation, muscle movement, and reflexes below the level of her injury.
- Muscle Weakness
- Altered Tone
- Altered Sensation
- Respiratory Difficulty
- Loss of Bowel and Bladder Function
- in all children admitted with head injury or unconscious - rule out spinal injury
How to determine mental status of a child suspect spinal cord injury?
Paediatric Galsgow coma scale
Differencials for spinal cord injury in children?
- Acute Torticollis
- Cauda Equina and Conus Medullaris Syndromes
- Cervical Strain
- Hanging Injuries
- Strangulation
- Neck Trauma
- Septic Shock
- Spinal Cord Infections
- Spinal Cord Neoplasms
- Thoracic outlet syndrome
https://www.physio-pedia.com/Paediatric_Spinal_Cord_Injury
Neuro revision for paediatric spinal cord injury. The three most important tracts in the spinal cord are corticospinal tracts, spinothalamic tracts, and dorsal (posterior) columns. How might injury to each of these manifest?
corticospinal tract
* descending motor pathway.
* Damage causes ipsilateral clinical findings including muscle weakness, spasticity, increased deep tendon reflexes, and Babinski sign.
Spinothalamic tract
* ascending pathway - transmits pain and temperature sensation.
* Damage results in loss of pain and temperature sensation on the opposite side of the body.
Dorsal columns
* Descending pathways for vibration and proprioception.
* Damage to one side of the dorsal columns causes ipsilateral loss of vibration and position sensation.
* A light touch is transmitted by both the spinothalamic tracts and the dorsal columns. Therefore, a light touch is preserved to some extent unless there is involvement of both the spinothalamic tracts and the dorsal columns.
https://www.ncbi.nlm.nih.gov/books/NBK442027/
Imaging for a child with spinal cord innjury?
Xray
* AP and lateral of cervical, thoracic and lumbar spine to see for fracture or dislocation - detects 80% injuries
* CT - do if polytrauma, high energy injuries, altered mental state
* MRI - most sensitive for detecting bony, ligamentous and cord injurys
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6513171/
How to manage spinal cord injury in a child ?
Pre hospital and in hospital
Pre-hospital Management:
* immobilization
* Paediatric respiration and airway: (key as hypoxia secondary to resp failure a major cause of cardiac arrest in paeds)
Hospital Management:
* ABC stability, with a rapid neurologic evaluation.
* Airway maintenance with cervical spine protection
* Breathing and ventilation
* Circulation with hemorrhage control e.g. BP / fluids
* imaging of spine further diagnosis and radiographic evaluation of the spine is needed.
* Positioning
* Meds - some people use corticosteroids to reduce swelling in spine
* catheter / nuritional support
* ITU support / surgery if needed
complications of spinal cord injuries in children ?
Pressure sores - immbolised
pneumonia - aspiration breathing support
spinal cord deformities
scoliosis
syringolmyelia
prognosis of spinal cord injury in children?
- Neurological injury has a better prognosis in children
- Incomplete lesions have a better prognosis compared to complete lesions.
- 10 - 25% of patients recover after complete spinal cord injuries.
- 64% partial recovery
https://www.ncbi.nlm.nih.gov/books/NBK442027/
Lightening learning status epilepticus
Child presents with a suspected seizure: what are differentials
Seizures, associate tiggering conditions, paroxysmal disorder
how is status epilepticus defined?
Child presents with a suspected seizure: what investigations (revision lecture Dr Luyt)
Key points in febrile seizures (Dr Luyt revision lec)
age, features, relevant negatives, associated risk
Childhood absence epilepsy (dr luyt rev lec)
age, features, prognosis, EEG findings
Infantile spasms (West syndrome) - Dr Luyt revision lecture
age, features, associations, EEG findings
Lennox-Gustaut syndrome (dr luyt rev lec)
age, features, prognosis
Benign rolandic epilepsy - dr luyt rev lecture
age, features, prognosis
FLOPPY INFANT: picture the pathway from the brain to a muscle (brain, spinal cord, motor never, muscle). At each point along the path think of causes of a floppy infant
Dr Luyt revision lecture : Spinal muscle atrophy
inheritance pattern, pathophyiology
Dr Luyt revision lec: Duchenne muscular dystophy
inheritance, clinical features, associated, life expectancy
Signs of what condition?
Duchenne muscular dystrophy
